CHILD BEHAVIOR FORM 1 1/2 - 5 FOR PARENTS (CBCL) REPORT FORM FOR TEACHERS OR CAREGIVERS FOR AGES 1 1/2 - 5

By Thomas M. Achenbach and Craig Edelbrock By Thomas M. Achenbach and Craig Edelbrock

Please specify parent's type of job, including if currently unemployed:

Please specify the type of job of the parents, even if in Mother: Father:
Name: is currently unemployed: Name:
Gender: M______F____________ Mother's job: Gender: M______F____________ Write your role at school:
Birthdate: _________________(day) ______(month) _____(year) Father's job: Birthdate: _________________(day) ______(month) _____(year) Write what your training is:
Application Date: _________(day) ______(month) _____(year) This questionnaire was completed by: Mother___Father______Other___ Application Date: _________(day) ______(month) _____(year) Years of experience as educators of boys and girls:

INSTRUCTIONS: Below is a list of items that describe your child as he or she is now or within the last two months. Please circle the number 2 if it is always or very INSTRUCTIONS: Below is a list of items that describe your child as he or she is now or within the last two months. Please circle the number 2 if it
often true or describes you a lot. Circle the number 1 if the item is somewhat or sometimes true for the student. If the item does not fit the student, circle the 0. is always or very often true or describes you a lot. Circle the number 1 if the item is somewhat or sometimes true for the student. If the item
does not fit the student, circle the 0.

1. Aches or pains (no medical cause; do not include 1. Aches or pains (without medical cause; do not include
0 1 2 stomach pain or headache) 0 1 2 52. Gets picked on by other kids 0 1 2 stomach pain or headache) 0 1 2 52. Gets picked on by other kids
0 1 2 2. He acts as if he were smaller at his age 0 1 2 53. Attacks people physically 0 1 2 2. He acts as if he were smaller at his age 0 1 2 53. Attacks people physically
54. He sticks his finger in his nose; scratches the skin or 54. He sticks his finger in his nose; scratches the skin or
0 1 2 3. You are afraid to try new things 0 1 2 other parts of the body (describe) 0 1 2 3. You are afraid to try new things 0 1 2 other parts of the body (describe)
0 1 2 4. Avoid eye contact with other people 0 1 2 55. He plays with his sexual parts too much 0 1 2 4. Avoid eye contact with other people 0 1 2 55. He plays with his sexual parts too much

0 1 2 5. You can't concentrate or pay attention for long 0 1 2 56. Poor coordination or clumsiness 0 1 2 5. You can't concentrate or pay attention for long 0 1 2 56. Poor coordination or clumsiness

0 1 2 6. Can't sit still, is restless, hyperactive 0 1 2 57. Eye problems (without medical cause) 0 1 2 6. Can't sit still, is restless, hyperactive 0 1 2 57. Eye problems (without medical cause)
0 1 2 7. Does not tolerate things being out of place 0 1 2 58. Punishment does not change your behavior 0 1 2 7. Does not tolerate things being out of place 0 1 2 58. Punishment does not change your behavior
0 1 2 8. He can't wait, he wants everything right away 0 1 2 59. Move quickly from one activity to another 0 1 2 8. He can't wait, he wants everything right away 0 1 2 59. Move quickly from one activity to another

0 1 2 9. Chew what is not edible 0 1 2 60. Rashes or skin irritation (no medical cause) 0 1 2 9. Chew what is not edible 0 1 2 60. Rashes or skin irritation (no medical cause)
0 1 2 10. Is dependent or attached to adults 0 1 2 61. Refuses to eat 0 1 2 10. Is dependent or attached to adults 0 1 2 61. Refuses to eat
0 1 2 11. Constantly seek help 0 1 2 62. Refuses to participate in active games 0 1 2 11. Constantly seek help 0 1 2 62. Refuses to participate in active games
0 1 2 12. Apathetic or unmotivated 0 1 2 63. Suddenly rock your head or body 0 1 2 12. Apathetic or unmotivated 0 1 2 63. Suddenly rock your head or body
0 1 2 13. Cry a lot 0 1 2 64. Inattentive, easily distracted 0 1 2 13. Cry a lot 0 1 2 64. Inattentive, easily distracted
0 1 2 14. He is cruel to animals 0 1 2 65. Resists learning to use the toilet 0 1 2 14. He is cruel to animals 0 1 2 65. Resists learning to use the toilet
0 1 2 15. Challenging 0 1 2 66. Yell a lot 0 1 2 15. Challenging 0 1 2 66. Yell a lot

0 1 2 16. Your needs must be met immediately 0 1 2 67. Seems not to react to affection 0 1 2 16. Your needs must be met immediately 0 1 2 67. Seems not to react to affection
0 1 2 17. Destroys his own things 0 1 2 68. Gets self-conscious and embarrassed easily 0 1 2 17. Destroys his own things 0 1 2 68. Gets self-conscious and embarrassed easily

0 1 2 18. Destroys the things of his family or other people 0 1 2 69.Selfish or refuses to share 0 1 2 18. Destroys the things of his family or other people 0 1 2 69.Selfish or refuses to share

0 1 2 19. You daydream or get lost in thought 0 1 2 70. Shows little affection towards people 0 1 2 19. You daydream or get lost in thought 0 1 2 70. Shows little affection towards people
0 1 2 20. Disobedient 0 1 2 71. Shows little interest in what surrounds him/her 0 1 2 20. Disobedient 0 1 2 71. Shows little interest in what surrounds him/her
0 1 2 21. Any change in routine disturbs you 0 1 2 72. Shows little fear of getting hurt 0 1 2 21. Any change in routine disturbs you 0 1 2 72. Shows little fear of getting hurt
0 1 2 22. He appears cruel, abusive, selfish 0 1 2 73. Too shy 0 1 2 22. He appears cruel, abusive, selfish 0 1 2 73. Too shy
0 1 2 23. He doesn't answer when people talk to him 0 1 2 74. Other children don't like him 0 1 2 23. He doesn't answer when people talk to him 0 1 2 74. Other children don't like him
0 1 2 24. Has difficulty following instructions 0 1 2 75. Super active 0 1 2 24. Has difficulty following instructions 0 1 2 75. Super active

0 1 2 25. He doesn't get along with other children 0 1 2 76. Problems speaking or pronouncing some words 0 1 2 25. He doesn't get along with other children 0 1 2 76. Problems speaking or pronouncing some words
26. He doesn't know how to have fun, he acts like a little 26. He doesn't know how to have fun, he acts like a little
0 1 2 adult 0 1 2 77.He stares into space 0 1 2 adult 0 1 2 77.He stares into space

0 1 2 27 . Doesn't seem to feel guilty after misbehaving 0 1 2 78. Stomach pains or cramps (without medical cause) 0 1 2 27 . Doesn't seem to feel guilty after misbehaving 0 1 2 78. Stomach pains or cramps (without medical cause)
0 1 2 28. Annoys other children 0 1 2 79. Excessively conforming to the rules 0 1 2 28. Annoys other children 0 1 2 79. Excessively conforming to the rules
0 1 2 29. Gets frustrated easily 0 1 2 80. Weird behavior 0 1 2 29. Gets frustrated easily 0 1 2 80. Weird behavior
0 1 2 30. Gets jealous easily 0 1 2 81. Stubborn, moody, irritable 0 1 2 30. Gets jealous easily 0 1 2 81. Stubborn, moody, irritable
0 1 2 31. Eat or drink things that are not food 0 1 2 82. Sudden mood swings often 0 1 2 31. Eat or drink things that are not food 0 1 2 82. Sudden mood swings often
32. You are afraid of situations, animals or places 32. You are afraid of situations, animals or places
0 1 2 (describe) 0 1 2 83. He gets in a bad mood often 0 1 2 (describe) 0 1 2 83. He gets in a bad mood often
0 1 2 33. He is easily offended 0 1 2 84. He makes fun a lot 0 1 2 33. He is easily offended 0 1 2 84. He makes fun a lot

0 1 2 34. Gets hurt frequently (accident prone) 0 1 2 85. He throws tantrums or has a bad temper. 0 1 2 34. Gets hurt frequently (accident prone) 0 1 2 85. He throws tantrums or has a bad temper.

0 1 2 35. He gets into fights a lot 0 1 2 86. Too worried about cleanliness or order 0 1 2 35. He gets into fights a lot 0 1 2 86. Too worried about cleanliness or order
0 1 2 36. He gets into everything 0 1 2 87. Too anxious or afraid 0 1 2 36. He gets into everything 0 1 2 87. Too anxious or afraid

0 1 2 37. He gets too upset when separated from his parents. 0 1 2 88. Uncooperative 0 1 2 37. He gets too upset when separated from his parents. 0 1 2 88. Uncooperative
0 1 2 38. Explosive or unpredictable behavior 0 1 2 89. Not very active, slow, or lacks energy 0 1 2 38. Explosive or unpredictable behavior 0 1 2 89. Not very active, slow, or lacks energy
0 1 2 39. Headaches without medical cause 0 1 2 90. Unhappy, sad or depressed 0 1 2 39. Headaches without medical cause 0 1 2 90. Unhappy, sad or depressed
0 1 2 40. They hit other people 0 1 2 91. Noisier than usual 0 1 2 40. They hit other people 0 1 2 91. Noisier than usual

0 1 2 41. Hold your breath 0 1 2 92. Gets upset with new situations or with new people 0 1 2 41. Hold your breath 0 1 2 92. Gets upset with new situations or with new people

0 1 2 42. Hurts other people or animals without intention 0 1 2 93. Vomiting (without medical cause) 0 1 2 42. Hurts other people or animals without intention 0 1 2 93. Vomiting (without medical cause)
0 1 2 43. He looks sad for no apparent reason 0 1 2 94. Poor personal appearance 0 1 2 43. He looks sad for no apparent reason 0 1 2 94. Poor personal appearance
0 1 2 44. Angry 0 1 2 95. Wander without direction 0 1 2 44. Angry 0 1 2 95. Wander without direction
0 1 2 45. Nausea, feels bad 0 1 2 96. Wants a lot of attention 0 1 2 45. Nausea, feels bad 0 1 2 96. Wants a lot of attention
0 1 2 46. Involuntary movements or tics (describe) 0 1 2 97. He complains a lot 0 1 2 46. Involuntary movements or tics (describe) 0 1 2 97. He complains a lot
0 1 2 47. Nervous or tense 0 1 2 98. He isolates himself, he does not relate to others 0 1 2 47. Nervous or tense 0 1 2 98. He isolates himself, he does not relate to others
0 1 2 48. Does not carry out assigned tasks 0 1 2 99. He worries a lot 0 1 2 48. Does not carry out assigned tasks 0 1 2 99. He worries a lot
100. Write down any other problems that the child has 100. Write down any other problems that the child has
0 1 2 49. Fear of staying at school 0 1 2 that are not included in this list: 0 1 2 49. Fear of staying at school 0 1 2 that are not included in this list:
0 1 2 50. He gets too tired 0 1 2 0 1 2 50. He gets too tired 0 1 2
0 1 2 51. Shows panic for no reason 0 1 2 0 1 2 51. Shows panic for no reason 0 1 2